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Laparoscopic Ureterolysis Without Omentoplasty in the Management of the Uropathy Secondary to Idiopathic Retroperitoneal Fibrosi

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Laparoscopic Ureterolysis Without Omentoplasty in the Management of the Uropathy Secondary to Idiopathic Retroperitoneal Fibrosi CASE REPORT Laparoscopic Ureterolysis without Omentoplasty in the Management of the Uropathy Secondary to Idiopathic Retroperitoneal Fibrosis Miguel A Bergero1, Patricio A Garcia Marchiñena2, Guillermo Gueglio3, Carlos David4, Fernando Dipatto5, Alberto Jurado6 ABSTRACT Introduction: Obstructive uropathy (OU) secondary to idiopathic retroperitoneal fibrosis (IRF) is an infrequent disease, and the standard treatment has not been established. However, ureterolysis with ureteral intraperitonealization is an effective therapeutic alternative. We present the successful management of OU secondary to an IRF by laparoscopic ureterolysis without omentoplasty (LUWO). Materials and methods: A retrospective descriptive study of 5 patients with IRF treated with LUWO was performed. Results: The average age was 60.4 years. The average creatinine was 3.86 mg/dL. There were no intraoperative or major postoperative complications. In a follow-up period of 31.2 months, all patients are asymptomatic, with an average creatinine level of 1.52 without dialysis requirement. No patients required corticosteroid therapy after surgery. Conclusion: Laparoscopic ureterolysis without omentoplasty is a safe and feasible option to treat the OU caused by IRF that provides good results in the medium-term follow-up, as we describe it in our series of cases. Keywords: Hydronephrosis, Laparoscopy, Retroperitoneal fibrosis, Ureteral obstruction. World Journal of Laparoscopic Surgery (2019): 10.5005/jp-journals-10033-1377 INTRODUCTION 1,4,5Department of Urology, Sanatorio Privado San Geronimo, Santa Fe, Obstructive uropathy (OU) related to idiopathic retroperitoneal Argentina fibrosis (IRF) is a rare disease characterized by retroperitoneal 2,3,6Department of Urology, Hospital Italiano de Buenos Aires, Buenos fibrosis. The pathology has theorized to be an inflammatory Aires, Argentina response to oxidized low-density lipoproteins.1,2 Because IRF has Corresponding Author: Miguel A Bergero, Department of Urology, 3–5 a very low prevalence, no treatments have been standardized. Sanatorio Privado San Geronimo, Santa Fe, Argentina, Phone: +54 Surgical ureterolysis with intraperitonealization (SUWI) has been 34299960, e-mail: [email protected] considered as a definitive treatment for ureteral obstruction caused How to cite this article: Bergero MA, Garcia Marchiñena PA, Gueglio G, by IRF. Usually, SUWI has been done open (open ureterolysis with et al. Laparoscopic Ureterolysis without Omentoplasty in the intraperitonealization (OUWI)), with a high success rate, >90%. Management of the Uropathy Secondary to Idiopathic Retroperitoneal But, with a high morbidity rate, 60%. Laparoscopic ureterolysis Fibrosis. World J Lap Surg 2019;12(3):126–129. ≥ with intraperitonealization (LUWI) of the ureter with or without Source of support: Nil omental wrapping has also shown a high success rate, >90% with Conflict of interest: None 4–9 a low morbidity rate <30%. However, there is still no prospective 7–9 randomized study comparing both techniques. The follow-up was performed with creatinine and renal scintigraphy 1 month after surgery and then at 6 months. MATERiaLS AND METHODS The correct functioning of the kidney was considered an adequate A retrospective multicenter descriptive study of 5 patients with renal function without requiring a urinary neither stent or dialysis OU secondary to retroperitoneal fibrosis treated surgically with treatment. laparoscopic ureterolysis without omentoplasty (LUWO) during the years 2012 and 2017 was performed. Surgical Technique The variables for the study were age, sex, symptoms at the Ureteral stenting was performed preoperatively. The patient was time of pathology’s presentation, blood analysis [erythrocyte placed in an extended plank position. Four ports sites were placed sedimentation rate (ESR), tumor markers, autoimmune disease according to the surgical technique (Fig. 1). markers, creatinine], imaging studies (ultrasound, computed In the first step of the procedure, the line of told was incised, and tomography or magnetic resonance, renal scintigraphy, positron the colon was deflected. The aorta and the external iliac artery were emission tomography), corticoids treatment, ureteral catheter clearly exposed. Close to the aorta and riding the iliac artery, the or nephrostomy. In addition, the variables related to the surgical encased ureter was identified and released from the fibrotic mass intervention were evaluated: surgical time (minutes), intraoperative using a blunt instrument (Figs 2 and 3). Once the ureter has been and postoperative complications (Clavien scale), bleeding (mL), pain completely released from the fibrotic tissue, along the full length management with pain ladder of the World Health Organization between the renal pelvis and iliac vessels, we proceeded with the (WHO) and time of hospitalization (hour). intraperitonealization of the ureter (Figs 3 and 4). © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons. org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Laparoscopic Ureterolysis without Omentoplasty Fig. 1: Disposition of laparoscopic ports in laparoscopic ureterolysis: the Figs 2A to E: (A) Ectasia of the renal pelvis; (B) Ureter compromised by initial port of 10 mm is placed pararectal at the level of the umbilicus retroperitoneal fibrosis; (C) Retroperitoneal fibrosis; (D) Muscle psoas; (laparoscopy). The second port of 10 mm is placed in the iliac fossa. The (E) Kidney other two remaining 5 mm ports are placed in the hemiclavicular line and the anterior axillary line in the upper abdominal quadrant Figs 3A to D: (A) Riding the external iliac artery (EIA), the encased ureter was identified; (B and C) Ureter was release from the fibrotic mass using a blunt instrument; (D) Pericolonic fat was interposed between the ureter and the fibrosis. Ao, aorta; Co, colon; EIA, external iliac artery; FM, fibrotic mass; P, psoas muscle; U, ureter World Journal of Laparoscopic Surgery, Volume 12 Issue 3 (September–December 2019) 127 Laparoscopic Ureterolysis without Omentoplasty In our cases, the peri-colonic fat was interposed between the ureter and the fibrosis (transposition of the ureter) without an omental wrapping. 6 weeks after surgery, the ureteral stent was removed. RESULTS Of the 5 patients analyzed, the average age was 60.4 years (55–67), and 80% were female. Sixty percent of patients had back pain and 40% oliguria. The average creatinine was 3.86 (1.2–8.6). All patients had negative autoimmune disease markers and tumor markers. The patient’s characteristics were described in Table 1. All patients underwent ULIP without omentoplasty. There were no intraoperative or postoperative complications major to Clavien 2 (1 patient presented a wound infection that required oral antibiotics). The average surgical time was 137 minutes (97–215) with an average blood loss of 84 (10–110) mL, without Figs 4A to D: (A) Kidney; (B) Intraperitonealization of the ureter; (C) requiring transfusions. The average time of hospitalized was Interposition of pericolonic fat with its fascia between the ureter and 51 hours (36–62), and all had mild pain that was controlled with the fibrosis; (D) Bladder non-steroidal analgesics. Table 1: Patient’s characteristics A/S CR Symptoms BT DI CTh PBS TTO PA Follow-up 67* ♂ Left RN (2005) Back pain, Cr 8.6 CT: right RF, OU No US Right IRF 2018:Ç oligoanuria (2013)Ç LUWI WO ESR: 80 MRI: IDEM No symptoms TM (−) RS: OU Cr 1.9 MAD (−) RS: no OU No CTh 63* ♀ Cholecystectomy 2014:Ç, Back pain (2016)Ç Cr 3.7 CT: left RF, OU Prednisone US Left LUWI IRF 2018:Ç right IRF + OU OUWI MRI: IDEM WO ESR: 95 RS: OU Intolerance No symptoms TM (−) PET: PAM Cr 2.1 MAD (−) RS, no OU No CTh 52* ♀ AH Back pain (2015)Ç Cr 1.3 CT: right RF, Prednisone US Left LUWI IRF IG4 2018:Ç OU. MRI: IDEM WO (+) ESR: 78 RS: OU Tamoxifen No symptoms TM (−) PET: PAM Cr 1 MAD (−) RS: no OU No CTh 65* ♀ Cholecystectomy Oligoanuria (2016)Ç Cr 4.5 CT: bilateral RF, Prednisone US Left LUWI IRF 2018:Ç OU. MRI: IDEM WO ESR: 87 RS: OU Intolerance No symptoms TM (−) RK no RP Cr 1.7 MAD (−) RS, no OU No CTh 55* ♀ No Asthenia weight loss Cr 1.2 CT: right RF Prednisone US Left LUWI IRF 2018:Ç (2017)Ç OU. MRI: IDEM WO ESR: 90 RS: OU Tamoxifen No symptoms TM (−) Cr 0.9 MAD (−) RS, no OU No CTh A/S, age and sex of the patients; CR, clinical record; BT, blood test; DI, diagnostic image; *, age; ♂, male; ♀, woman; RN, radical nephrectomy; AH, arterial hyper- tension; Ç, year; Cr, creatinine (mg/dL); ESR, erythrosedimentation rate (mm/hour); TM, tumor markers; MAD, markers of autoimmune disease; CT, computed tomography; MRI, magnetic resonance imaging; RS, renal scintigraphy; PET, positron emission tomography; OU, obstructive uropathy; RK, right kidney; LK, left kidney; RF, retroperitoneal fibrosis; IRF, idiopathic retroperitoneal fibrosis; LUWI, laparoscopic ureterolysis with intraperitonealization; LUWI WO, laparoscopic ure- terolysis with intraperitonealization without omentoplasty; OUWI, open ureterolysis with intraperitonealization;
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